Founding Principles of the Oregon POLST Program
Building an Interprofessional Task Force
A volunteer task force was founded on the guiding principles of always working for the benefit of patients, using an open consensus process to invite interested parties to the table, using a continuous quality improvement process that welcomes critical feedback with the goal of seeking truth, and avoiding and managing conflicts of interest.
Building a POLST Coalition
Task Force Composition & Initial Form Development
Over a two-year period, a task force was formed from a group of health care professionals, including emergency medical services (EMS), medicine, nursing, hospice, and long-term care. Their purpose was to address the common problem of not locating and thereby honoring the life-sustaining preferences of patients with an advanced chronic progressive illness who were nearing the end of life. The Medical Treatment Coversheet (MTC) was designed to help health care professionals honor the treatment preferences of their patients.
Obtaining Endoresements and Selecting a Name
“Physician Orders for Life-Sustaining Treatment (POLST)”
In parallel with the Oregon Legislature’s recently adopted advance directive statute, the MTC was refined with focus group feedback from clinicians caring for patients in acute and long-term care settings. The name was changed to “Physician Orders for Life-Sustaining Treatment (POLST)” to distinguish the medical order form more clearly from a traditional advance directive. For the program to succeed statewide, health care professionals received updates on form use, newly developed policies and advances in research. The task force developed numerous educational resources and relied on member organizations to develop effective on going learning for their constituents.
EMS Education and Pilot Testing
Assuring POLST will be Honored by EMS and Emergency Medicine
Dr. Terri Schmidt, an emergency medicine physician and a county EMS medical director, along with Jerry Andrews EMT-P and other EMS professionals helped assure that POLST development and implementation was designed in ways that could be honored by EMS providers and emergency medicine physicians statewide. The initial form, developed by Oregon ethics leaders, EMS, and all of the member stakeholders was modified with EMS fully engaged as partners in every step of the revision process. Prior to clinical use first responders were given clinical scenarios to assure orders would never result in under treatment (see annotation of Journal of the American Geriatrics Society, 1996;44, 785-791). Once this pilot testing was complete and prior to statewide dissemination of the Oregon POLST Program, Dr. Schmidt led an intensive EMS educational effort. As with other professional groups, EMS education has been and needs to be supplemented with additional yearly instruction.
Oregon Launches POLST Statewide
Facilitating Statewide POLST Use
Guided by evaluation findings, the task force released a slightly revised version of the POLST form for use throughout Oregon. The task force used data from research and employed a continuous quality improvement method to actively elicit feedback from clinicians and patients and families using the form. For example, a prospective one-year study of POLST form use in eight nursing homes demonstrated effectiveness; no resident with orders for Comfort Measures Only and DNR received CPR, ventilator support or ICU care (see annotation of Journal of the American Geriatrics Society, 1998;46, (9), 1097-1102).
Protections Added to EMS Scope of Practice
Changes Made to the Oregon Medical Board’s Administrative Rules
For the POLST form to be effective, emergency personnel wanted further protection from liability when honoring POLST orders. To address this, the task force recommended a change in the Oregon Medical Board’s administrative rules defining the Scope of Practice for EMT’s/First Responders (OAR 847-035-0030). The Board approved language states:
An Oregon-certified First Responder or EMT, acting through standing orders, shall respect the patient’s wishes including life-sustaining treatments. Physician supervised First Responders and EMTs shall request and honor life-sustaining treatment orders executed by a physician, nurse practitioner or physician assistant* if available. A patient with life-sustaining treatment orders always requires respect, comfort and hygienic care.
*Nurse practitioners and physician assistants were added as signers in 2001 and 2007 respectively.
Oregon is the First State to Authorize Nurse Practitioners as POLST Signers
Regulations Changed to Include NPs and Clarify POLST Use for Minors
Community clinicians requested the task force consider use of the POLST form for children with terminal illness. A community and task force consensus process included focus group input from various professionals and health care organizations that care for children and from the school system. The Oregon POLST Task Force modified the program to include minors and recognized parents as the surrogate for their terminally ill child, consistent with Oregon law.
Nurse practitioners (NPs) provide primary care for a substantial number of Oregonians. In the early years of the program POLST forms for NP patients needed to be signed by a supervising physician even though these orders were similar to other NP orders not requiring this signature. The task force worked with the Oregon Board of Nurses in determining that POLST orders are within the scope of practice for NP’s and therefore do not require physician co-signature. Emergency Medical Service (EMS) responders were not allowed to take orders from nurses so the task force worked with EMS to ensure that POLST orders signed by an NP could be followed by EMS based on their standing orders from their EMS supervising physician.
OHSU Center for Ethics Convenes the National POLST Paradigm Task Force
The Founding 6 States of the National POLST Paradigm Task Force
The initial criteria for state inclusion in the NPPTF was a minimum of three years’ experience using the POLST paradigm at the regional or statewide level. In 2004, only six states met this requirement: OR, WA, WI, PA, NY and WV. In 2004, the Oregon POLST Program was the most mature program with longest history and had the strongest research program, the most EMS experience and the highest level of penetration in long-term care. As a result, the composition of the initial thirteen founding NPPTF included five members from Oregon [Patrick Dunn, MD, Chair (OR) and Susan Tolle, MD, Treasurer (OR), Bud Hammes, PhD (WI), Woody Moss, MD (WV), James Shaw, MD (WA), Sally Denton, (WA), Judy Black, MD (PA), and Patricia Bomba, MD (NY) with advisors Terri Schmidt, MD (EMS), Margaret Carley, JD (Long-term Care), Susan Hickman, PhD (Research), Charles Sabatino, JD (Legal), and Malene Davis (Hospice)].
Dr. Susan Tolle led funding efforts for the NPPTF from inception to 2015. The NPPTF adopted the same standards of accepting private donations and grants only, and not accepting funding from health care industry sources (NPPTF conflicts of interest policy). By mutual agreement the NPPTF could not accept health care industry support as long as they were part of the OHSU Center for Ethics. Effective January 20, 2017, the NPPTF became independent of the OHSU Center for Ethics and approved a change in its funding policy, allowing support from health care industry sources. As of March 2017, the differences in NPPTF and the OHSU Center for Ethics policies are being considered by the Oregon POLST Coalition and the Center.
POLST Steps onto the Federal Stage
Presenting POLST to the White House Conference on Aging
Drs. Judy Black and Susan Tolle presented on behalf of the National POLST Paradigm Task Force to the White House Conference on Aging (WHCOA): Care Coordination Across the Continuum.
OMB Rule Authorizes Portability and PAs as Approved Signers
More Changes to Oregon Medical Board’s Administrative Rules
In 2006, some emergency physicians and health care systems raised concerns about following POLST orders signed by a health care professional who was not on their medical staff. In order to clarify this issue, the task force worked with the Oregon Medical Board (OMB) to establish new administrative rules. In addition, leaders in the physician assistant (PA) professional community requested that PAs be considered as signers of POLST orders. In 2007, the Board included PAs in rule changes regarding respecting orders for life-sustaining treatment in all Oregon health care facilities. OAR 847-010-0110 states:
- (1) A physician or physician assistant licensed pursuant to ORS Chapter 677 shall respect the patient’s wishes including life-sustaining treatments. Consistent with the requirements of ORS Chapter 127, a physician or physician assistant shall respect and honor life-sustaining treatment orders executed by a physician, physician assistant or nurse practitioner. The fact that a physician, physician assistant or nurse practitioner who executed a life-sustaining treatment order does not have admitting privileges at a hospital or health care facility where the patient is being treated does not remove the obligation under this section to honor the order. In keeping with ORS Chapter 127, a physician or physician assistant shall not be subject to criminal prosecution, civil liability or professional discipline.
- (2) Should new information on the health of the patient become available the goals of treatment may change. Following discussion with the patient, or if incapable their surrogate, new orders regarding life-sustaining treatment should be written, dated and signed.
Clarifying Appropriate POLST Use for Persons with Disabilities
POLST & Individuals with Intellectual/ Developmental Disabilities
The Oregon POLST task force convened health care and disability leaders to clarify how POLST should be used for persons with disabilities, specifically Intellectual/Developmental Disabilities. The goal of this collaboration was twofold, to:
- Assure that persons with disabilities who are nearing the end of life receive high quality care, and
- Prevent the use of POLST in those persons with stable disabilities who lack life threatening conditions.
Since that time, the guidelines have been rewritten to reflect ever changing aspects within Oregon law. To view the updated guidelines: POLST Use for Persons with Disabilities, click HERE.
The Oregon POLST Registry Launches Statewide
HB 2009 Funds the Oregon POLST Registry
A pilot project was funded by private philanthropy, including a grant from The Greenwall Foundation and gifts from individual donors, with the goal of enhancing POLST form access to locate a needed POLST in the first few minutes when EMS were on scene.
The first phase of the project consisted of designing the electronic registry. In January 2009, the second phase began, with system training and testing of the developed registry by the project team, with the OHSU Emergency Communications Center and EMS professionals in Clackamas County. May 2009 marked the roll out of the third phase or “pilot” of the Oregon POLST Registry with initiation in Clackamas County on May 26, 2009.
Concurrently, task force leaders worked to facilitate legislation to create and fund the Oregon POLST Registry, which would be “owned” by the Oregon Health Authority but operated under contract by the OHSU Department of Emergency Medicine. The legislation addressed HIPAA requirements, mandated that health care professional signers (or their designees) submit forms unless the patient opted out and provided funding for the Registry. All other aspects of the POLST program including form revision remained under the leadership of the Oregon POLST Task Force administered by the OHSU Center for Ethics. The legislation became law on July 1, 2009 and the Registry office began accepting forms from all of Oregon. On December 3, 2009 the Oregon POLST Registry was implemented statewide.
POLST Trademarks, Leadership & Succession Planning
Protecting the POLST Program
Leading the Oregon POLST Program
1990 – 2010: Patrick Dunn, MD
2010 – 2013: Margaret Carley, JD
2013 – 2014: Amy Vandenbroucke, JD
2015 – Present: Susan Tolle, MD
The Center for Ethics recognized the need to protect the identity of the POLST program because of some well-meaning groups that wanted to emulate POLST yet were not meeting the rigorous standards initially developed by the Oregon POLST Program. The concern was centered on the quality of programs and their care of patients and not concerns for any proprietary protection. The Center for Ethics in Health Care at OHSU, the initial administrative home for the National POLST Paradigm Task Force, successfully received approval for three trademarks related to its efforts: “POLST,” “POLST Paradigm,” and the program’s visual graphic of the “O” in POLST.
The Oregon POLST Task Force recognized the need to encourage participation by leaders from various health care professions. Physician, EMS, nurse and legal leadership are essential and Oregon has been fortunate to have strong representation from each of these disciplines. In addition, the Oregon POLST Task Force required the dedication and administrative expertise of its program coordinators. These talented individuals were supported by the Center for Ethics in Health Care at OHSU, keeping the task force organized with its myriad projects. The position has grown from part-time to now full time given the growth in the responsibilities of the coordinating position.
Oregon Removes the Antibiotics Section
Data Supports the Removal of the Antibiotic Section
Early on, the Oregon POLST Task Force and subsequently the National POLST Paradigm Task Force (NPPTF) recognized the promises and perils of various funding sources. Accepting support from private donations and grants limits the ability to raise much needed funds. Broadening potential funding to include health care industry sources would have been in some ways easier, yet increased the risk of conflicts of interest. For example, if funding was accepted from a well-meaning insurance company, the public might perceive that the program’s primary goal was to save health care dollars by encouraging the limitation of treatments. To ensure that any actual, potential or perceived conflicts of interest were either avoided or managed, in 2009, the NPPTF adopted a policy similar to OHSU’s Center for Ethics’ policy, the administrator of the Oregon POLST Program.
Since Oregon created the first POLST form, that form served as a model for all other states. Initial versions of the Oregon POLST Form included four sections addressing preferences for CPR, Scope of Treatment, Antibiotics and Artificially Administered Nutrition. The Oregon POLST Task Force pursued research data to inform each step of the form’s revision process. Early data confirmed that orders in Section A (CPR/DNR) and Section B (Scope of Treatment) were highly correlated with the level of treatments patients received.
A three state (OR, WV, WI) 90 nursing home study led by Susan Hickman Ph.D., was the first study to examine the degree to which orders related to antibiotic use were honored (see annotation of Journal of the American Geriatrics Society, 2011; 59(11):2091-2099). In a 60 day period about one third of residents of skilled nursing facilities received antibiotics. The rate was the same irrespective of the order to administer or forgo antibiotic use suggesting that orders in the antibiotic section had little impact on the treatment patients ultimately received.
Once a state POLST program is in wide spread use, making major revisions to the form is difficult. After years of debate, this new data led the Oregon POLST Task Force to remove the separate antibiotic section in 2011 and incorporate the use of antibiotics under ‘Scope of Treatment’ in Section B.
The task force was aware of these results several years prior to publication of this study and shared the findings with colleagues in developing states. As a result several states did not include a separate antibiotic section in the first version of their state’s POLST form.
Expanding POLST Research
Research Guides POLST Education, Policy and Implementation
A cornerstone of POLST research seeks answers to help develop sound policy, and identify the most effective methods in education and implementation. In short, the program seeks truth, always aiming to improve the care of those served. For more information on the growing list of research publications, please see Scholarly Publications on our Resources page.
The Inclusion of ePOLST Technology
Two Health Systems Launch ePOLST Form Completion & Registry Submission
As electronic medical records became the norm, many groups expressed interest in developing electronic versions of POLST. Providence Health and Services in Oregon worked with the POLST Task Force to create a pilot and was the first to develop an electronic POLST completion system (Epic Smart Form). Providence worked closely with the Oregon POLST Registry to create a secure electronic submission system.
In April of 2015, OHSU developed a partnership with the Vynca ePOLST system which provides an electronic completion system accessed within Epic with direct submission to the Oregon POLST Registry. To ensure that POLST orders can be accessed with a single click, the “ePOLST Yes/No” tab was included on the patient header (Oregon POLST policy recommendation). The system was designed to facilitate bidirectional communication with the Oregon POLST Registry.
The Oregon POLST Task Force produced a cautionary video, “The POLST: Doing It Better,” to promote high quality use of the POLST program.
National Recognition of Oregon POLST
The Flame of Excellence Award & the Community Insight Committee
The “Flame of Excellence” was presented to Dr. Susan Tolle at the 2016 national POLST conference to honor Oregon’s outstanding service in support of the National POLST Paradigm. Four Oregon leaders (Margaret Carley, JD, Patrick Dunn, MD, Susan Tolle, MD, Terri Schmidt, MD) have made major contributions to the national advancement of the POLST paradigm by serving as consultants to other states.
The Oregon POLST Program added a new committee to expand direct representation of members of the lay public. The Oregon POLST Task Force continued to have members representing AARP and Oregon Health Decisions. In addition to public advocacy group representation, in February 2016 the Community Insight Committee was created adding greater diversity and a more direct pathway for collaboration with community members.
Oregon Separates from the POLST Paradigm Office
Oregon POLST Coalition Reaffirms Its Values for Avoiding Conflicts of Interest
Effective March 2017, the Oregon POLST Task Force changed its name to the Oregon POLST Coalition. After more than 25 years of development and service, members decided its name should reflect its intended permanent commitment. The group has been successful in its mission to develop a new method to translate patient preferences into actionable medical orders that follow patients across settings of care. The Coalition will continue to strengthen POLST education, technology, quality improvement, community involvement, and innovative research.
In June 2017, the Oregon POLST Coalition reaffirmed its foundational values of not accepting support from the health care industry. Actions include: 1) clarifying the Center for Ethics policy on conflicts of interest (a policy that the Coalition honors as the Center serves as its administrative home) and 2) withdrawing membership from the National POLST Paradigm Task Force (NPPTF) because of its 2017 policy change to accept health care industry funding.
To preserve public trust and the program integrity, it is essential that Oregon POLST accept support only from non-health care industry sources. To accept health care industry funding could imply a conflict between the Oregon POLST Program goal to honor patient choice and possible cost saving that would benefit industry. Center policy does not allow funding from commercial health care related entities including, but not limited to, insurance companies, pharmaceutical manufacturers, device makers and other health care product suppliers. The policy also does not allow Center leaders to have associations with health care industry.
Gifts from private individuals play a vital role in funding program innovation and building an endowment that will permanently sustain the Oregon POLST Program. We gratefully acknowledge Bill and Karen Early for their contribution of $1 million to launch the endowment fund with a $4 million goal. We are thankful also to all of the individuals who have and continue to support the POLST program. Several of these individual donors requested that they be acknowledged anonymously.
Oregon Authorizes NDs as Signers
Expanded the Scope of Practice of Naturopathic Doctors
The Oregon Legislature (2017 SB 856) expanded the scope of practice of naturopathic doctors (NDs) to include the ability to sign POLST forms effective January 2, 2018. Of the 46,188 POLST forms entered into the Oregon POLST Registry in 2018, 56 (0.12%) forms were completed by 14 NDs (range 1 to 37).
Oregon Removes Feeding Tube Section & Changes the Name of the Form
POLST Becomes "Portable" Orders for Life-Sustaining Treatment
When POLST was originally established only physicians (M.D. and D.O.) could sign POLST orders. In 2018, the Oregon POLST Coalition recognized that using the word “physician” in the description of POLST was not inclusive of all disciplines currently authorized to sign POLST orders. Effective January 2, 2019, the Oregon POLST form was changed to “Oregon POLST® Portable Orders for Life-Sustaining Treatment.”
To improve the quality of readability of faxed and photocopied POLST forms, the Oregon POLST Coalition voted to no longer produce a solid pink POLST form. Effective January 2, 2019, the Oregon POLST form became a black and white form with a pink border.
The artificially administered nutrition section of the POLST form was originally created to promote planning in the context of advancing dementia. In the early 1990s when Oregon created the POLST program, it was thought that placement of a feeding tube extended life for those with advanced dementia; now we know this is not true. (“American Geriatrics Society Feeding Tubes in Advanced Dementia Position Statement”). After careful review of quality data, the Oregon POLST Coalition voted to remove the artificially administered nutrition section from the Oregon POLST form. On January 2, 2019, Oregon became the first state to remove artificially administered nutrition from its POLST form (J Am Geriatr Soc. 2019 Jan 31, https://doi.org/10.1111/jgs.15775). Click here to learn more by listening to the GeriPal Podcast, “Time to Remove Feeding Tubes from POLST.”
Turning a Page: Oregon Promotes Broader Access to High Quality End-of-Life Care during the Covid-era
A Commitment to Fight Against Discrimination in End-of-Life Care
On September 24, 2020, Oregon POLST Coalition adopted its Statement Against Discrimination in End-of-Life Care:
The Oregon POLST® Coalition endorses the efforts of our member organizations to stand against systemic racism and injustice. The Oregon POLST Program is committed to fight against discrimination in end-of-life care for all people, regardless of their race, religion, national origin, citizenship status, gender, gender identity, sexual orientation, physical or intellectual disability, age, or socioeconomic status.
We honor diversity and support inclusion in the care of the patients we serve who are nearing the end of their lives. Inequality and bias can both impair access to necessary medical treatments and lead to reduced access to high-quality end-of-life care. In response to the values expressed in this statement, the POLST Coalition has published guidelines related to the use of POLST for persons with significant disabilities that we hope are useful to those who support and provide care to people with disabilities. (See Guidelines on POLST Use for Persons with Significant Disabilities – updated and approved in July 2020.)
Oregon’s New Innovations
Improved Quality Reporting and Provider Access
The Oregon POLST Registry’s new platform has expanded quality reporting capabilities with the creation of reports for comparisons between individual health systems and statewide POLST submission data, among other useful metrics. Other metrics include: Total number of form submissions (including Not Registry Ready forms), percentages Section A metrics (CPR/DNR), average age of Section A (CPR/DNR) and percentages of form submissions by gender. These reports allow POLST submitting healthcare systems to track their own metrics and implement better quality control measures internally.
The Registry has developed a new Provider Portal. This freestanding ePOLST portal will permit providers, who would otherwise not have access to a bi-directional platform integrated in their EHR, to gain access to the full POLST Registry database. Access to the free Provider Portal will require a separate logon. For those organizations that can afford it, the gold standard for ePOLST remains as a single logon and one-click access within the patient’s EHR.
The Oregon POLST Coalition’s subcommittee for Quality Improvement voted unanimously to authorize health systems to implement a “hard-stop” on Section C within ePOLST systems, if they so choose. Those using ePOLST may require documentation of who was present for a POLST discussion. Providence, Kaiser, Vynca and the OPR Provider Portal have implemented this change in their ePOLST systems. Paper forms are not impacted by this change.